This is another guest blog from our friend and colleague Andy Volans, Consutlant in Emergency Medicine.
We’ve all been subjected to the challenge of the “Expert Patient”. Our GP colleagues probably get it more as they sit with internet warriors asking for the latest investigation or treatment that they have seen on line. It’s a common problem in modern medicine.
We normally deal with these questions professionally, using our medical knowledge to guide our patients back to reality, though even I will admit to using Dr Google on occasion, taking a sneaky look before trying one of my more trusted sources to make myself confident when turning them from a daft or possibly harmful course of activity. The point is that the ‘informed’ patient can be challenging in the internet age.
However, what happens when the “expert patient” is a senior clinician, even worse a Consultant, and the ultimate, your senior Consultant, the one who does your appraisals?
This blog is about how the ‘expert patient’ can sometimes present unexpected difficulties as the system tries to mould around them. I hope you find my experiences interesting (I certainly have), and there’s some clinical learning along the way too. It’s a but longer than the usual post, (Ed – there is a reason for that), but I hope it makes you pause for thought.
This is my story and that of my department. I am an “Old School” ED physician, having been around from before we had a College. Yes I am that old!
My background included 6 month medical and surgical SHO jobs that allowed me to practice ED, Neurosurgery, a year of Anaesthesia and the entry exam, followed by 2 years as a Surgery SHO (lots of us wanted to be surgeons in the 80s). I achieved my FRCS and then did Orthopaedic middle grade posts until eventually deciding on brain surgery and transferring into that (amazingly we could do that back then). Then along came MMC and I was forced to stop drilling holes in heads and went off to seek interest and suitable mad work mates in ED. I wandered around Manchester filling a locum role and I learned a lot.
Later I slipped over the border to “God’s Own County” (Yorkshire) and made my own training program (including 6 months in General practice , painful, but massively educational) and eventually got a Senior Registrar post in Sheffield and passed the first ever specialty exam in what we now call emergency medicine (the FFAEM).
At that time, much like now, there was a shortage of people for the places available and you could choose. Most places were 1 or 2 handed, there were one or two “multiple Consultant sites” where we were talking 5 at max. Small centres mean you are a big fish in a small pond, no one else knows what you should be doing, so, you do what you want, and for me that meant a wonderful job on the East coast of England in a place called Scarborough.
Scarborough is not a tertiary centre, it does not have (self declared) super specialised centres of excellence around every corner nor is it especially large. However, it’s been a super place for me and my family and I’m proud to have spent many great years there. The joy and pressure of a small unit is the intimacy that you develop with your staff, you are there a lot, and your life is not yours. Annual leave drops away, but you have the moral high ground and you do what you feel is right for you and yours. Maybe it’s considered old school these days, but I do feel that we put ourselves in personal and familial discomfort to make the service work and perhaps that shaped my older mind.
Enough background but let us say that the result of this, is that the “Old Git” is “loved” by his team which is fantastic, but it’s not all wonderful. The problem with being the ‘Old Git’ is that occasionally they get deferred to when they shouldn’t be.
So why am I back and writing on St.Emlyn’s?
Having semi retired and discovered that there is much more life out there to enjoy; sadly this enthusiasm for life led me to fall off my mountain bike. Before you ask, yes, I was wearing a helmet, (remember my previous life as a Neurosurgeon). I was knocked out on impact but only briefly, certainly less than 2 mins. I had no pre-trauma amnesia longer than 30 seconds, but did have a 40 minute post traumatic memory loss with that irritating repetitive questioning according to my long suffering wife. So, I was not completely fine and realised that it could not be ignored so we did what most of us would do. We visited our own ED. I arrived, was seen in our pretty rigid assessment process and quite appropriately (according to the NICE guidelines) I got a lovely CT that looked normal, felt normal and was reported as normal.
I returned to part time work and did the next weekend on the floor without too many problems, but as days passed I was finding it harder and harder to go in to work. My rationalisation was that I was too old for this, I didn’t like the NHS politics, I wasn’t feeling as confident as I once was, and although I loved the patient care and the teaching I was increasingly wondering whether the way I was feeling was a way for my mind and body to say that it’s time to stop. That would mean losing that close link to my extended family and status, the thought of which kept me going, but there is no doubt that these were difficult times. I began to wonder if was developing a depressive illness or perhaps, even worse, following the path of my mother towards the suffering and pain of dementia.
My mind was one thing, my body another. The neck pain that came on some days after the accident was not really improving, of course I rationalised this as “whiplash” but it was getting steadily worse. There was a tender spot on my left occipital muscular insertion that surely (?) proved it be musculoskeletal, but the fact that this pain woke me in the morning and disappeared when I got up and made the morning tea didn’t really add up. In retrospect this pain pattern should have triggered me to consider other diagnoses. Finally there was the mild dyspraxia on my right side…… I called that concussion….or was this denial?
So what happened next?:
I was not getting better, but had a great little birthday party to look forward to. I did the cooking and socialising, but that bottle of beer I had was not the same as usual. Although I’m no big drinker, (I could never drink, lack of practice from my work / life balance), a bit of alcohol has never given me a migraine like that before. Initially it responded as my migraines normally do with simple medication but the next day it came back, that wasn’t normal.
Having now run out of meds and maybe feeling a little anxious I made a quick phone call to the department to check on how busy they were, (in retrospect I was an idiot). Of course they were busy! So I left it, but nothing settled and I realised later that I needed help.
So the “Old Man” makes his own way to the ED, arrives and is treated as a VIP. I am bypassed around the “Assessment” area because it is busy, and I interfere in my care, gently advising and cajoling my friends and colleagues into what I need. I’m no longer just the patient, but also trying to be my own doctor in my own department, after all in my head I am the expert.
The staff are great. The lovely young doctor writes me up an effective medication regimen, an ACP did a nice cannula, she had to go and get one as we were in a side room and the gear wasn’t there (as it’s kept in the assessment area, which is where I probably should be too). The bloods were taken since there was a cannula in place and sent off to the lab. I hear someone say “get the B***** scanned” behind the curtains. I heard it, but no one else did, and it didn’t happen.
Another doc comes to review me and is equally pleasant. I tell them that I’m clearly improving and would like to go home please. I want and need to sleep and the pain is less. In passing I notice the blood sodium is 127 (Normal Range 135-145) which is a little odd. I consider a diagnosis of “Inappropriate ADH secretion”1 but I knew I hadn’t got a brain tumour as I saw that initial trauma CT and so I think no more about it. I discuss what next with the second Doctor who has been with me for a while. There is a power/age/authority gradient at work here and although he is a good clincian I’m a strong willed and skilled clinical negotiator after years of practice at the coal face of NHS medicine. I don’t expect him to stand up to the old man and persuade him to let me go home? After all, what could possibly go wrong……..
What did go wrong?
I was in trouble. Three hours after returning home the pain returned with a vengeance with a side order of persistant nausea and vomiting. I had to return to the department, again for a cannula and a realisation that I needed a repeat CT scan. No debates this time and as the pictures below show this was serious. A significant subdural haematoma and an urgent referral to our Neurosurgery Unit.
I am still here after some wonderful care, a burr hole (odd to be getting one, rather than doing one as I did in my neurosurgical youth) and the luxury of time for reflection on what happened and why. What else though? Am I simply an interesting case or am I a key player as an expert, informed (maybe not always fantastically well informed), participant, patient in this process? Am I part of my own pathway in a way that a non VIP patient might not be?
As I recuperate and reflect, I look to my colleagues who like me will quite likely end up in their own departments at some point in the future. I’ve put together a few thoughts and ideas.
So what can we take away form this as a learning event?
1. Being an “Expert” does not always give you insight when the symptoms come on slowly and may be subtle. You’re not a great judge of your own health.
2. As an old school clinician I think that being male means you don’t talk about stuff to your mates like women do. That may be sexist I know, but unfortunately more or less true in my observation. There’s far too much macho bluster from the idiot male and we should do better.
3. When you have a safe process in your department (and our Assessment process has been audited and is a safe process), then follow it. For everyone. Assessment units get criticised for over investigation and occasionally misses stuff, BUT the processes and aide memoires are there to help you. Use the systems that you have to make life easier for everyone (e.g. getting bloods done). A process driven chain burger bar provides faster and more consistent “reasonable” quality burgers at a lower cost than a fashion joint where the 3 star chef can have a hissy fit. I regretted our assessment units when they first arrived it but the numbers show it works and now my personal experience backs that up too.
4. The message: DO NOT do VIP care! As soon as we start doing different then we are as likely to harm as help. When you are looking after a colleague, give them the grace to accede to some of their suggestions. Do the basics well. Take a full history as you normally would and examine the VIP as you normal. I have no problems with seeing patients I know out of respect and politeness, but only after they have had the safe system processing. Insist on this2.
5. Clinical history trumps almost everything in medicine. Had I revealed and been asked more about my symptomatology at my second attendance I’m sure that I would have got an earlier second CT (I’d even mentioned some at work as a joke in the week previously). A good clinical history could have set alarm bells off. That advice applies to me too. I had a consultant behave in the same way as I did quite recently; he didn’t succeed in changing my opinion because I used first principles, a good history and examination. It’s not about being clever, it’s just about being a diligient clinician.
6. If your department doctors are new or easily swayed then make sure your team is robust. We have had a standing rule that if the nurse feels the Doctor is being “sandbagged” or bullied by a patient, of any sort, then they will sneak off and talk to a senior, at any time of day or night. In Scarborough that means speaking to a consultant (there are only three of us). That did not happen during this event and there was a 5-hour delay because of it, much of it, my making. If you are the boss who is called in to move things along and avoid a disaster then be kind and understanding. There have been many occasions in the last 20 odd years when I have ‘accidently’ turned up during the night to have a quiet word; understand the discomfort to the junior and explain. If you do then all will be well and you will retain the respect of the team. Most of my past staff (and there are a fair few) seem to have survived the experience without needing counselling. Some still speak to me 😉
- No matter how good a department is, and I love mine with a passion (told you I am a dinosaur) it can always be better.
- The ‘expert patient’ can be dangerous but simple safe processing reduces that danger.
- Do not take the “expert’s diagnosis” for granted, no matter how senior, always do the simple skills we were taught in medical school.
- No one else noticed my low sodium on my first visit, yet roughly a third (32%) of acute head injuries may have low sodium with ADH secretion believed to be the cause (so any FRCEM candidates might want to look out for a question on this soon).
- Have systems set up in your department to counter the real problems that VIPs can encounter. It’s pretty simple in theory but does demand a tight team who trust each other and look after each other.
My journey was not perfect but I’m still here and incredibly grateful to my gang and our Neurosurgery colleagues (much as it strains an EP to say so). I’m pretty certain that my experience is not one in a million, and that it could happen to your department or even to you. We can plan for the peculiar and special patients like me, we should talk about them and make sure that we don’t cause harm through deference and defence.
I’m just as proud of my team as I always have been, and I’ll be delighted to work with them for a few more years yet. There are a few more hurdles to jump over but I’m going to be getting back on the bike (metaphorically and in reality) very soon. If you see me at college or at the conference then say hello. I’m the guy with the hole in his head.
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